Reinserting Tracheostomy Tube

<< RESPIRATORY

  • The changing of a tracheostomy tube in the school setting should be considered an emergency situation
  • Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed.
  • The two most common emergency scenarios are:
    • accidental decannulization; and
    • tracheostomy tube obstruction unrelieved by reasonable suction attempts.

Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.

Considerations:

  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • The changing of a tracheostomy tube in the school setting should be considered an emergency situation
  • Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed.
  • The two most common emergency scenarios are:
    • accidental decannulization; and
    • tracheostomy tube obstruction unrelieved by reasonable suction attempts.

Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.

Supplies:
Emergency Travel Bag Equipment:
The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen ( if ordered)
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
  • portable suction machine that can operate with battery or electricity
  • sterile suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Needed Supplies:

  • Stethoscope
  • Medical tape
  • Personal protective equipment
    • goggles
    • mask
    • gloves

procedure download skill competency

  1. Activate EMS/911
  2. Reassure student
  3. Wash hands, if student’s condition permits
  4. Assemble equipment as student’s condition permits or utilize equipment in emergency travel bag
  5. If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
  6. Ensure the presence of another responsible adult, preferably another nurse if available, to assist with stabilizing the tracheostomy tube
  7. Put on gloves, goggles, and mask
  8. Have adult assisting with procedure put on gloves, goggles, and mask
  9. Suction the student’s tracheostomy tube, if indicated (see Tracheal Suctioning-Clean Technique)
  10. If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck
  11. Open the new tracheostomy tube kit that is the same size as is currently in the stu­dent
    • Have the size smaller new tracheostomy tube readily available if needed
  12. If new tube is not available, clean the old tube as possible
  13. Take care to not touch the curved part of the tracheostomy tube
    • If the tube has an obturator, be sure the obturator is in the tube
  14. Lubricate the distal end of the new tracheostomy tube with water-based lubricant return it to the clean package that it was sealed in
  15. Remove tracheostomy mask, artificial nose or ventilator connection, as necessary
  16. Give student two to four breaths with resuscitation bag
    • If unable to pass suction catheter, do not attempt to give breaths to a plugged trach. CHANGE THE TRACH TUBE
  17. Have adult assisting with procedure hold old tracheostomy tube in place
  18. Assure tracheostomy tube cuff has been fully deflated, if applicable
    • Deflate the cuff per manufacturer’s instructions
  19. Remove or cut old tracheostomy ties
  20. With one hand remove the old tracheostomy tube and set it out of the way
  21. Insert new tube
    • If tube does not have an obturator, insert new tube at a right angle to the stoma, rotating it downward as it is inserted
    • If tube has an obturator, insert tube straight into stoma
      • Immediately remove the obturator and insert inner cannula (if trach tube has inner cannula)
        • Note many pediatric trach tubes do not have an inner cannula
    • Insertion of new tube should take no longer than 30 seconds
  22. Have adult assisting with the procedure hold the new tracheostomy tube in place
  23. Administer a minimum of three breaths with a manual resuscitator bag
  24. Secure the new tracheostomy tube in place by fastening the tracheostomy ties:
    • If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s in­structions
  25. Re-attach tracheostomy mask, artificial nose or ventilator connection, as necessary
  26. Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any)
  27. Continue the respiratory assessment, using pulse oximetry, if available, until EMS has arrived
  28. Discard used equipment per school policy
  29. Remove gloves
  30. Wash hands
  31. Document assessment, intervention and outcomes in student’s healthcare record
  32. Notify parents/guardian and medical provider that student required a tracheostomy change procedure
  33. Replenish supplies in emergency travel bag

If unable to replace tracheostomy tube:

  1. Reposition the student and re-attempt to place the tube
  2. If unsuccessful, attempt to place the smaller tube
  3. If unable to place a size smaller tube, assess child’s respiratory status to determine the need for rescue breathing
    • If rescue breathing is needed
      • Open the natural airway
        • Be aware that some patients may not have a natural airway due to surgical procedures or anatomical abnormalities
      • Tape over the tracheal stoma
      • Give breaths using a manual resuscitation bag with a facemask
    • If rescue breathing is not needed and child’s respiratory status is stable
    • Observe the child and call 9ll for assistance. 

References:

American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Children’s Hospital of Wisconsin.  (2006).  Tracheostomy Cares and Trach Tube Changes: Policy and Procedure.

Connecticut State Department of Education. (2012). Clinical Procedure Guidelines for Connecticut School Nurses. Available at:
http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Hootman, J.  (1996).  National Association of School Nurses.  Quality Nursing Interventions in the School Setting.

Porter, S., Haynie M.D., Bierle, T., Caldwell, T. & Palfrey, J. (1997). Children and Youth Assisted by Medical Technology in Educational Settings. Guidelines for Care. Second Edition. Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624

Acknowledgment of Reviewers:

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Cecilia Lang, MSN, CCRN, PNP-BC
Tracheostomy/Home Ventilator APN
Children’s Hospital of Wisconsin

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Page last updated: November 10, 2015
Page last reviewed: November 10, 2015